Internet of Things to Explore Moment 2 of "WHO My Five Moments" for Hand Hygiene

Background: Electronic hand hygiene surveillance systems are developing and considered to be more reliable than direct observation for hand hygiene monitoring. However, none have the capability to assess compliance in complex nursing care.

Materials and Methods: We combined two different technologies, a hand hygiene monitoring system (radiofrequency identification, RFID) and a nursing care recorder at the bedside, and we merge their data to assess hand hygiene performance during nursing. Nursing tasks were classified as standard task procedures or aseptic task procedures corresponding to moment 2 among the five moments for hand hygiene recommended by the WHO. All statistical analyses were performed using R, version 3.6.2. For mixed models, the package “lme4” was used.

Results: From the merged database over the 2-year study period, 30,164 nursing tasks were identified for analysis, 25,633 were classified as standard task procedures, and 4,531 were classified as aseptic task procedures for nursing care. Hand disinfection with an alcohol-based solution was not detected with our system in 42.5% of all the recorded tasks, 37% of all the aseptic task procedures, and 47.1% of all the standard task procedures for nursing (p = 0.0362), indicating that WHO moment 2 was not respected in 37% of mandatory situations.

Conclusion: Using a combination of different technologies, we were able to assess hand hygiene performance in the riskiest circumstances.

Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial

BACKGROUND

Chloroquine and hydroxychloroquine have been found to be efficient on SARS-CoV-2, and reported to be efficient in Chinese COV-19 patients. We evaluate the effect of hydroxychloroquine on respiratory viral loads.

PATIENTS AND METHODS

French Confirmed COVID-19 patients were included in a single arm protocol from early March to March 16th, to receive 600mg of hydroxychloroquine daily and their viral load in nasopharyngeal swabs was tested daily in a hospital setting. Depending on their clinical presentation, azithromycin was added to the treatment. Untreated patients from another center and cases refusing the protocol were included as negative controls. Presence and absence of virus at Day6-post inclusion was considered the end point.

RESULTS

Six patients were asymptomatic, 22 had upper respiratory tract infection symptoms and eight had lower respiratory tract infection symptoms. Twenty cases were treated in this study and showed a significant reduction of the viral carriage at D6-post inclusion compared to controls, and much lower average carrying duration than reported in the litterature for untreated patients. Azithromycin added to hydroxychloroquine was significantly more efficient for virus elimination.

CONCLUSION

Despite its small sample size, our survey shows that hydroxychloroquine treatment is significantly associated with viral load reduction/disappearance in COVID-19 patients and its effect is reinforced by azithromycin.

The effect of a single dose of oral ivermectin on pruritus in the homeless

BACKGROUND

Homeless people commonly present with ectoparasite-based pruritus. We evaluated the efficacy of a single dose of ivermectin to reduce the pruritus prevalence in a homeless population.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial from January 2006 to April 2006 in two homeless shelters in the city of Marseille, France. Homeless people complaining of pruritus were randomized to receive either ivermectin (24 mg) or placebo. Follow-up visits were planned at day 14 and day 28 after the inclusion to assess the outcome of pruritus.

RESULTS

Forty-two subjects with pruritus were randomized to the ivermectin group and 40 to the placebo group. On day 14, pruritus was reported by significantly more subjects in the placebo group than those in the ivermectin group for both the per-protocol (PP) population (91.42% versus 68.57%, P = 0.014) and the intention-to-treat (ITT) population (92.5% versus 73.80%, P = 0.038). No significant effect was observed at day 28. Ivermectin was the only independent factor associated with the absence of pruritus at day 14 in both PP population [OR: 4.60 (95% CI:1.13; 18.73), P = 0.033] and ITT population [OR: 4.38 (95% CI: 1.07; 17.77), P = 0.039].

CONCLUSIONS

A single dose of oral ivermectin has a transient beneficial effect on the reduction of the prevalence of pruritus in the homeless population. More studies are required to assess the efficacy of multiple repeated treatments with ivermectin to reduce scabies and body lice endemic among homeless people with pruritus and the impact of such treatment on this population.

Prevalence of skin infections in sheltered homeless

In an attempt to determine the prevalence of various skin infections in the homeless population in Marseilles, France, we undertook a case control study. Cases were recruited among institutionalized homeless subjects during two snapshot investigations conducted in January 2002 and 2003 respectively. The control subjects were recruited from among those who presented at a clinic for pre-travel advice. We recruited 498 cases and 200 control subjects. Compared to control subjects, a significantly higher proportion of cases had skin diseases (38% versus 0.5%; p < 0.0001). Pruritus, body-lice infestation, scratching lesions, folliculitis, tinea pedis, scabies and impetigo (ecthyma) were strongly significantly associated with homelessness. The higher prevalence of skin infections in the homeless people mainly results from the body-louse infestation, scabies, bacterial super-infection of skin surfaces that have been breached by frequent scratching and tinea pedis due to poor foot hygiene.

Ectoparasitism and vector-borne diseases in 930 homeless people from Marseilles

Homeless people are particularly exposed to ectoparasites, but their exposure to arthropod-borne diseases has not been evaluated systematically. A medical team of 27 persons (7 nurses, 6 infectious disease residents or fellows, 2 dermatologists, and 12 infectious disease specialists) visited the 2 shelters in Marseilles, France, for 4 consecutive years. Homeless volunteers were interviewed, examined, and received care; and blood was sampled for cell counts and detection of bacteremia, antibodies to louse-borne (Rickettsia prowazekii, Bartonella quintana, and Borrelia recurrentis), flea-borne (R. typhi, R. felis), mite-borne (R. akari), and tick-borne (R. conorii) bacterial agents. We selected sex- and age-adjusted controls among healthy blood donors. Over 4 years, 930 homeless people were enrolled. Lice were found in 22% and were associated with hypereosinophilia (odds ratio, 5.7; 95% confidence intervals, 1.46-22.15). Twenty-seven patients (3%) with scabies were treated with ivermectin. Bartonella quintana was isolated from blood culture in 50 patients (5.3%), 36 of whom were treated effectively. The number of bacteremic patient increased from 3.4% to 8.4% (p = 0.02) over the 4 years of the study. We detected a higher seroprevalence to Borrelia recurrentis, R. conorii, and R. prowazekii antibodies in the homeless. Our study shows a high prevalence of louse-borne infections in the homeless and a high degree of exposure to tick-borne diseases and scabies. Despite effective treatment for Bartonella quintana bacteremia and the efforts made to delouse this population, Bartonella quintana remains endemic, and we found hallmarks of epidemic typhus and relapsing fever. The uncontrolled louse infestation of this population should alert the community to the possibility of severe re-emerging louse-borne infections.

A focus of tick-borne relapsing fever in southern Zaire

Relapsing fevers occur worldwide and are characterized by recurrent episodes of fever and spirochetemia. In central, eastern, and southern Africa, the disease is often caused by Borrelia duttonii, which is transmitted by the soft tick Ornithodors moubata. We conducted a field investigation in September 1994 at a hospital in Mitwaba, southern Zaire, which was the only medical facility within 150 km. The introduction of a rapid blood-smear staining technique allowed us to demonstrate that 4.3%-7.4% of the 25-50 new outpatients seen each day had relapsing fever. Because of the absence of malaria in this area, these patients account for most of the febrile patients. The incidence of relapsing fever among all pregnant women in the maternity ward was estimated to be 6.4%, and this condition often led to maternal death or to spontaneous abortion. The 16S rRNA gene of B. dutonii was sequenced after the spirochete was isolated from patients' blood samples and directly from Ornithodoros tick vectors. In this region of Africa, relapsing fever should now be considered an important public health priority.

Survey of the seroprevalence of Bartonella quintana in homeless people

Trench fever is caused by Bartonella (Rochalimaea) quintana, a small gram-negative rod that is transmitted by body lice. Recently, B. quintana infections in homeless patients have been reported in the United States and Europe. From October 1993 to October 1994, the seroprevalence of antibodies to B. quintana was assessed by indirect immunofluorescence in a prospective study of 221 nonhospitalized homeless people, 43 hospitalized homeless patients (cases), 250 blood donors, and 57 hospitalized matched controls. Four (1.8%) of 221 nonhospitalized homeless people tested had titers of > 1:100. Of the 43 cases, seven (16%) had serological titers of > or = 1:100. None of the 250 serum samples from blood donors contained antibodies to B. quintana. The presence of antibodies to B. quintana in cases was significantly associated with the presence of body lice, exposure to cats, headaches, eastern European origin, and pain in the legs. This study demonstrates the presence of antibodies to B. quintana in the homeless population and should alert physicians that B. quintana might be an etiologic agent of fever in homeless patients.

[Acute pericarditis in Coxiella burnetti infection. Apropos of a case]

The authors report a case of pleuro-pericarditis during an acute Coxiella burnetii infection. They point out the rarity of this mode of presentation of acute Q fever and the diagnostic difficulties in the absence of focal pulmonary or hepatic signs. The diagnosis was confirmed by serological changes, essentially indirect immunofluorescence. They underline the importance of early diagnosis before the disease become chronic, exposing the patient to more serious cardiac disease which may be difficult to treat.

Prevalence of antibodies to Coxiella burnetti, Rickettsia conorii, and Rickettsia typhi in seven African countries

The prevalences of antibodies reactive with Coxiella burnetti, Rickettsia conorii, and Rickettsia typhi were determined by indirect fluorescent antibody testing of sera from seven African countries. The seroprevalences of antibodies reactive with C. burnetti and R. conorii in countries from North Africa were similar to those reported from southern Europe. In countries of sub-Saharan Africa, the seroprevalence of antibodies reactive with C. burnetti varied greatly; the generally higher figures for West Africa, where stock breeding is prominent, suggested that domestic animals might be the main reservoirs of infection. The prevalence of antibodies to the recently described species Rickettsia africae was higher than that reported for spotted fever-group rickettsiae from elsewhere in the world and paralleled the distribution of Amblyomma species. Western blot results suggested that the antibodies detected were more likely to be reactive with R. africae than with R. conorii, the main vector of which (Rhipicephalus species) rarely feeds on humans. The seroprevalences of antibodies reactive with R. typhi were higher in coastal regions, where Rattus norvegicus--the natural host of the vector Xenopsylla--is more prevalent, than in inland areas.

Seroepidemiological survey of rickettsial infections among blood donors in central Tunisia

In this report we attempt to evaluate the prevalence of antibodies against Rickettsia conorii, R. typhi, Coxiella burnettii, and Ehrlichia chaffeensis in central Tunisia. Five hundred sera from blood donors, collected between March and June 1993, were tested for these 4 antibodies using an indirect immunofluorescence antibody assay (IFA). Nine percent of the sera had antibodies against R. conorii (IgG > 1:32) by IFA, and 8% by Western blotting; with IFA, 3.6% had antibodies to R. typhi, 26% to C. burnetii (> 1:50), and none to E. chaffeensis. Infection rates with R. conorii and R. typhi did not differ significantly between the sexes, but fewer young people had antibodies to R. typhi. A significantly higher prevalence of antibodies to C. burnetii was noted for males with no difference between age classes. No significant difference was detected between urban and rural areas. This study confirmed the endemicity of rickettsioses, and revealed a high seroprevalence of Q fever, in central Tunisia.

Identification of rickettsiae from ticks collected in the Central African Republic using the polymerase chain reaction

Spotted fever rickettsiosis have been identified on the African continent since their historical description in 1909. However, only Rickettsia conorii and R. africae have been described in Africa, and the current techniques for the detection of rickettsiae in ticks are difficult to apply in large field studies. We report here a preliminary study using genomic amplification by the polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) analysis directly on 310 crushed ticks (Rhipicephalus, Amblyomma, and Haemaphysalis species) collected in 1985 in the Central African Republic. Among 310 specimen tested, 21.6% were positive. The rate of infection ranged from 0% to 64.3%, depending on the tick species. Based on PCR-RFLP, five different rickettsiae profiles were found: R. conorii and R. africae, previously known in Africa, R. rhipicephali, which has never been described in Africa, and two isolates identical to R. massiliae and Mtu5, previously obtained from Rh. turanicus in southern France. This work shows that PCR-RFLP is a powerful tool to study tick collections, and that it is applicable to samples from developing countries. Further work is needed to confirm the identification of the rickettsiae found in this work, using traditional identification procedures.

Q fever serology: cutoff determination for microimmunofluorescence

Q fever, a worldwide zoonosis caused by Coxiella burnetii, lacks clinical specificity and may present as acute or chronic disease. Because of this polymorphism, serological confirmation is necessary to assess the diagnosis. Although microimmunofluorescence is our reference technique, the cutoff titers that are currently used to make a diagnosis of active or chronic Q fever were determined years ago with limited series of patients and sera. We determined the titers of immunoglobulin G (IgG), IgM, and IgA against both phases (I and II) of Coxiella burnetii. Rheumatoid factor was removed before testing IgM and IgA. We report here the various cutoff titers and the kinetics of antibody development from 2,218 first serum samples of patients, among whom 208 suffered from acute Q fever and 53 had chronic Q fever. In active Q fever, we have defined a low cutoff (phase II IgG titer < or = 100) below which the diagnosis cannot be made and would need further confirmation and confirmed a high cutoff (phase II IgG titer > or = 200 and phase II IgM titer > or = 50) over which the diagnosis can be made. For chronic Q fever diagnosis, phase I IgA titers are not contributive despite previous works claiming their usefulness; a phase I IgG titer of > or = 800 is highly predictive (98%) and sensitive (100%). We have also studied the possibility of rejecting or evoking the diagnosis of chronic Q fever by phase II IgG and IgA titers. This method is useful when phase I testing is not available, but the sensitivity remains low (57%).

Rickettsia conorii in Greece: comparison of a microimmunofluorescence assay and western blotting for seroepidemiology

Since 1972, there have been no reports of Mediterranean spotted fever (MSF) in Greece. In 1991, a seroepidemiologic survey was conducted in three rural villages in the Province of Fokida in central Greece, using both an immunofluorescence assay (IFA) and Western blot to evaluate the prevalence of specific IgG and IgM antibodies to Rickettsia conorii, and to compare these two techniques. Of 254 sera tested by IFA, 148 (58.3%) were positive for IgG at a titer > or = 32 and 117 (46.1%) at a titer > or = 64. Two sera were positive for IgM at a titer > or = 32. Among the IFA-positive sera, 115 reacted against the specific protein antigen (SPA) using Western blotting and were considered as confirmed positive results, indicating a seroprevalence of 45.3%. Using the SPA reaction as a reference, the IFA diagnostic value of a single serum is poor in such an endemic area, suggesting the need for more specific tests. The results of this study have led us to conclude that for seroepidemiologic use, the IFA is not specific for MSF. Thus, the IFA is useful for sero-epidemiologic analysis only in areas where the true prevalence of MSF has been estimated using Western blotting.

Chronic Q fever. Ninety-two cases from France, including 27 cases without endocarditis

OBJECTIVE

Chronic Q fever is seldom recognized; before 1989, only 234 cases had been reported in the literature. The 92 cases of chronic Q fever collected at the French National Reference Center for Rickettsioses from 1982 through 1990 represent the largest series ever reported.

PATIENTS

The patients included in the study were diagnosed between July 31, 1982, and August 1, 1990, at the French National Reference Center for Rickettsioses as having chronic Q fever by the following criteria: presence of antibody against Coxiella burnetii phase I antigen at a titer greater than or equal to 800 for IgG and 50 for IgA by the indirect immunofluorescence test. Epidemiologic, clinical, laboratory, and treatment data were collected from 39 different collaborative hospitals throughout France.

MAIN OUTCOME MEASURE

For each serologically selected patient, a computerized questionnaire was utilized to record 188 different items of demographic, epidemiologic, clinical, laboratory, and therapeutic data, which were analyzed.

RESULTS

Chronic Q fever occurs more frequently in city dwellers than in rural inhabitants, and exposure to domestic ruminants and raw milk is an important feature. Immunocompromising conditions (20.2%) and underlying heart disease (88.4%) or vascular disease are the most important risk factors to consider in potential cases of chronic Q fever. The mortality in these patients with endocarditis was high (23.5%). The clinical spectrum of 84 patients included 57 cases of endocarditis, three cases of vascular prosthesis infection, three cases of aneurysmal infection, three cases of osteoarthritis, four cases with lung localizations, nine asymptomatic cases, three cases of hepatitis, and two cases with cutaneous forms of the disease.

CONCLUSIONS

In patients with unexplained fever, negative blood cultures, and a history of underlying vascular or cardiac disease, Q fever should be considered.

Mediterranean spotted fever in Marseille, France: correlation between prevalence of hospitalized patients, seroepidemiology, and prevalence of infected ticks in three different areas

We report the results of a comparison of several epidemiologic and ecologic parameters affecting the incidence and seroprevalence of Mediterranean spotted fever (MSF) in northern, central, and southeastern Marseille, an area endemic for this disease. In northern Marseille, the incidence of hospitalized patients with MSF was 24.2/100,000 persons compared with 9.8/100,000 and 8.8/100,000 for the central and southeastern regions, respectively. The seroprevalence in sera from blood donors, determined by microimmunofluorescence and confirmed by Western blot assays, was higher in the northern region than in the other two areas (6.7% versus 3.6% and 2.4%, respectively). This higher prevalence of MSF in the northern part of the city may be related to a greater tick exposure due to a higher number of dogs (32.6/100 inhabitants versus 28.4/100 and 27.2/100 in the central and southeastern regions, respectively) and a higher rate of infection of dogs in the northern region (51.4% versus 43.5% and 39.9%, respectively). The ratio of spotted fever group rickettsia-infected ticks was similar in both the northern and southeastern areas (14.8% and 13.4% respectively), but lower in the central area of the city (8.9%), leading to a higher risk of having MSF after a tick bite in the northern and southeastern parts of Marseille.

Q fever and HIV infection

OBJECTIVE

To study the frequency of Q fever in HIV-infected individuals.

DESIGN

A seroprevalence study.

SETTING

French National Reference Centre for Rickettsial Agents, Marseille, France.

PATIENTS AND METHODS

Five out of the 68 hospitalized cases of Q fever diagnosed in 1987-1989 were also HIV-infected and are described here. Sera from a blood-donor bank (n = 925) and from HIV-positive individuals selected at random, irrespective of clinical or immunological status (n = 500) were tested for Q fever.

RESULTS

Comparisons of the two groups showed a statistically significant difference (2.4 versus 0.8%; Fisher's exact test) at the diagnostic dilution 1:200 and at the dilution considered positive for seroprevalence study (1:1000).

CONCLUSIONS

Using the estimated incidence of HIV infection in Marseille, the number of Q fever cases in 1987-1989 was 13 times higher and the clinical expression more frequently symptomatic in the HIV-positive population than in the general one. The prevalence:seroprevalence ratio for Q fever was 1.37% in the HIV-positive group and 0.36% in the blood-donor group. Sera positive for Q fever were confirmed by Western blot analysis in order to minimize cross-reaction. Transmission of Q fever appears to be more frequent in HIV-positive individuals than in the general population; this is not surprising, since Coxiella burnetii lives in the phagolysosome, like other micro-organisms described in immunocompromised hosts. Q fever should be added to the spectrum of diseases that occur more frequently during HIV infection.

Spotless boutonneuse fever

Mediterranean spotted fever is endemic in southern France, especially during summer. Clinical diagnosis is generally based upon the presence of a febrile eruption with or without the typical tache noire. Usual laboratory findings, which include thrombocytopenia, elevated levels of hepatic enzymes, and hyponatremia, are not specific to the disease. The diagnosis may be confirmed serologically by obtaining specific western immunoblot results and by isolation of Rickettsia conorii from blood culture with use of the shell vial cell culture technique. We report here the first documented case of spotless boutonneuse fever.